Derbyshire Dales Council for Voluntary Service

Derbyshire Dales Council for Voluntary Service

THE FARMING LIFE CENTRE

APPLICATION FOR THE POST OF

Macmillan Rural Health Outreach Coordinator

Please note that this front sheet contains only your personal details. It will be removed from your application prior to the short-listing process.

PERSONAL DETAILS

Full Name ……………………………………………………………………………………………..

Address……………………………………………………………………………………..…………

…………………………………………………………………………………………….……………

Postcode…………………………………………….

Phone No: Daytime …………………………….. Evening ………………………………………..

Mobile number ………………………………….. E. Mail ………………………………………….

REFEREES:

(Please give the details of two referees, neither of whom should be related to you. One should know you professionally and be able to comment on your paid, voluntary or student work. Referees will be approached by letter only if you are successful at interview)

Name …………………………………..…. Name …………………………………………….

Address…………………..……………….. Address ………………………………………….

……….…………………………………….. …………………………………………………….

………………………………….….………. …………………………………………………….

…………………………….……….………. …………………………………………………….

Daytime phone no: ..…………….………. Daytime phone no: ………..…………………….

Fax no: ……………………………….…... Fax no: ……………………………………………

Mobile no: ………………………………... Mobile no: ………………………………………...

E-Mail: …………………………….……… E-Mail: …………………………………………….

CRIMINAL RECORD:If you have been convicted for any crime or offence please give full details: ……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

If the position you are applying for involves the provision of services to schools or the training of young people or working with vulnerable adults, you are obliged under the Rehabilitation of Offenders Act 1974 Exemption Amendment Order 1986 to disclose any previous convictions.

(Only related convictions will be considered in the selection process. A full criminal records check will be undertaken if successful, as outlined in Farming Life Centre policy)

DISABILITY: Do you identify yourself asdisabledYES/NO

DECLARATION OF INTENT

I confirm that I am submitting this as an application for the post of Rural Health Outreach Coordinator

The information contained within this application is correct to the best of my knowledge.

Signature ______Date ______

1.Education History

Please give brief details of all education, and any qualifications achieved.

DateSubject/CourseSchool/College etcQualification

2.Training

Please include career development, personal development and anytraining relevant to the post.

DateSubject/CourseTraining ProviderQualification

3.Employment history.

Please give details of all employment, with your most recent employment listed first.

Job Title:______

Name/Address of Employer______

______

Dates employed: From ……………………………. To ………………………..

Main responsibilities:

Job Title:______

Name/Address of Employer______

______

Dates employed: From ……………………………. To ………………………..

Main responsibilities:

Job Title:______

Name/Address of Employer______

______

Dates employed: From ……………………………. To ………………………..

Main responsibilities:

Job Title:______

Name/Address of Employer______

______

Dates employed: From ……………………………. To ………………………..

Main responsibilities:

Please copy this sheet and continue as necessary.

4. Skills, knowledge and experience

Please use this section to describe and demonstrate how you meet the requirements contained in the job description and the person specification.

Please continue on a separate sheet if necessary.

5.Community and Voluntary Experience

Please give details of any community or voluntary work you have beeninvolved in.

6.Continuing Education and Training

Please give details of any current or planned education or training.

7. Other information

Please add here any other information that you feel is relevant to, or supports, your application.

Please continue on a separate sheet if necessary.

When completed please return this form electronically to arrive no later than 12 noon on Monday 7th August 2017. All receipt of applications will be acknowledged by email.

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